Provider Demographics
NPI:1811087836
Name:MODRA, CARRIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:
Last Name:MODRA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7811 GENEVA DR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9156
Mailing Address - Country:US
Mailing Address - Phone:847-404-9264
Mailing Address - Fax:
Practice Address - Street 1:1800 HOLLISTER DRIVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1111
Practice Address - Country:US
Practice Address - Phone:847-918-7947
Practice Address - Fax:847-918-9622
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist